NEW YORK (Reuters Health) - In the family disputes that
surrounded American radio icon Casey Kasem's last weeks of life,
his daughter's decision to carry out Kasem's wish - to suspend
artificial feedings and fluids - was among the most contested.

Kasem's advance directive called for no life-sustaining
treatment if it "would result in a mere biological existence."
But his wife opposed a court order allowing an end to artificial
measures; her attorney called it a "functional equivalent of a
death sentence."

The Kasem family infighting is unfortunately not unique. It
mirrors the struggles of countless other families, whether their
loved ones have dementias like Kasem's, or advanced cancers and
other terminal conditions.

The choice of when to stop artificial feeding and fluids is
one of the hardest families face when caring for a patient
nearing death. The decision is entwined with fears of
abandonment, violations of cultural norms and moral concerns.

"The relational meaning of eating and drinking is important
and something we must hold dear," said Mildred Solomon,
president of the Hastings Center, a bioethics research
institute. However, the significance of eating and drinking may
have more value for caregivers than for patients in the last
days of life.

"If people are entering the dying process, then imposing
artificial nutrition is not only not helpful, it can actually be
harmful," Solomon told Reuters Health. Feeding tubes are shown
to often result in pain, heartburn, accidental inhalation of
fluids and infections.

Kasem's wife claimed the decision to allow the suspension of
these measures was an order "to kill" him. Some experts in
"comfort care," however, say those measures can actually do the
same.

"It actually makes people, in some cases, die quicker," said
Michael Marschke, a palliative care specialist at North Shore
University Health Systems in Evanston, Illinois.

"As the body declines, it is not able to accept much
nutrition," he told Reuters Health. "Patients can't process it
and can't digest it."

Marschke explains that bed-bound patients like Kasem require
only 400 to 800 calories daily. Appetite diminishment is a
natural process for most with advanced diseases.

Marschke said the medical utility of a feeding tube is one
of the most emotionally-laden issues among caregivers. While
beneficial for many with reversible conditions (for example, a
stroke patient who's temporarily unable to swallow), tube
placement will not restore strength at the end of life, as
families often believe. Others may fear a decision against
artificial feeding will be the cause of a loved one's death.
They may be anxious to not "starve" the patient.

However, to what degree physicians should indulge the
symbolic act of nourishment poses an ethical dilemma.

"It is one in a series of other decisions we're helping them
talk through," said Mark Kuczewski, chair of the Neiswanger
Institute of Bioethics at Loyola University-Chicago. Other
issues, like a decision regarding cardiopulmonary resuscitation,
are more clear; it is easier, he told Reuters Health, for
families to understand CPR could cause pain, so they often opt
to forego it. However, the point when patients stop processing
or enjoying food is not so clear cut.

Kuczewski encourages families to orally feed patients
capable of swallowing, even if they only take a teaspoon or two.
Caregivers enjoy the nurturing benefit of feeding, while
patients may benefit from social interaction.

"If they only want a couple of bites, that's great,"
Marschke said. He urges families to feed only things that
patients enjoy; at the end of life, pleasure should be more
paramount than nutritional value.

"Modern medicine is not able to stop this process of the
final phase of life," Solomon said.

Kasem died four days after the order that artificial
measures could cease.

Solomon asks those newly diagnosed with serious illnesses to
think about this issue ahead of time and explain preferences to
key loved ones. Kasem's advance directive dates to 2007, though
family conflict concerning its contents suggests he did not
verbally express his desires and values behind them.

Technology is not always in patients' best interest, Solomon
said, and the administration of artificial nutrition and
hydration does not equate to the symbolic significance of
sharing a meal.